Phalloplasty

ABSTRACT

A method of widening a penis wherein a dermal fat graft comprising a block of fat and attached dermis is excised from the patient, the penis is degloved, the dermal fat graft is sutured to the exposed Bucks fascia and then reducing the penile skin; said method further including the step of following a post-operative treatment regime.

RELATED APPLICATIONS

This application is a continuation application of U.S. application Ser.No. 10/520,959, filed Sep. 15, 2005, which was the U.S. National Phaseof PCT/AU03/00400 filed Apr. 3, 2003 which claims priority to AustralianApplication No. 31403/02 filed Apr. 3, 2002, which are herebyincorporated by reference in their entirety herein.

BACKGROUND

This invention relates to enhancement phalloplasty, which is a surgicalprocedure to modify the human penis, normally by increasing the lengthof or widening the penis.

There are several reasons for persons requiring operations of this type.The first is for persons who are born with small penises. These personscan often believe that they are the subject of derision and ridicule andthe lack of size of the appendage can be emotionally very difficult forthem.

A second is where persons, either for personal pleasure or forprofessional reasons, such as strip-tease dancers, actors and the like,wish to be seen to have a large penis.

There have been previously proposed methods of enhancement phalloplastybut these have not been fully successful.

The major object of the invention is to provide methods of enhancementphalloplasty which provide satisfactory results and which are safeprocedures and which result in lengthening the penis in both the flaccidand erect states.

The applicant has disclosed basic surgical procedures in earlier filedpatent applications including Australian Patent Applications 28601/97,53864/98 and 79900/98. However these applications are for a basesurgical procedure. It is an object of the present invention to combinethese surgical procedures and others with post-operative treatmentmethods thereby to maintain the outcome of the basic surgical procedure.

BRIEF DESCRIPTION OF INVENTION

Accordingly, in one broad form of the invention there is provided amethod for penile enlargement further including the step of applicationof a post-operative treatment regime.

Accordingly, in another broad form of the invention there is provided amethod for penile enlargement further including the step of applicationof a post-operative treatment regime thereby to maintain outcome ofenlargement.

Accordingly, in yet another broad form of the invention there isprovided a method of widening a penis wherein a dermal fat graftcomprising a block of fat and attached dermis is excised from thepatient, the penis is degloved, the dermal fat graft is sutured to theexposed Bucks fascia and then reducing the penile skin; said methodfurther including the step of following a post-operative treatmentregime.

Preferably the dermal fat grafts are harvested from either the buttocks,lower back or lower abdomen.

Accordingly, in yet another broad form of the invention there isprovided a method of lengthening the penis of a male which includes thesteps of placing the suspensory ligament under tension in the inferiordirection; dividing the suspensory ligament against the body of thesymphysis pubis down to the inferior pubic arch and along the inferiorsurface of both the right and left conjoined inferior pubic rami;effecting suturing to retain the penis released from the suspensoryligament in an inferior position by coapting the proximal medialattachments of the right and left gracilus muscle together ventral thereleased penis, dividing the fundiform ligaments, drawing the skin ofthe junction site of the scrotum and the perineum mediosuperiorally soas to attach it to the symphysis pubis thereby pushing the skin adjacentthereto along the newly exposed shaft of the penis and suturing this toretain this position; said method further including the step offollowing a post operative treatment regime.

Preferably followed by the insertion of additional sutures through theanterior surface of the symphysis pubis; said sutures also placedthrough the margins of the pubic skin wound and tied in such a manner asto pull suprapubic skin down infrapubically.

Preferably the number of said additional sutures inserted is 1 or more.

Preferably the number of said additional sutures is determined by thewidth of the symphysis pubis.

Preferably including the step of dividing the fundiform ligament priorto said step of drawing the skin of the junction site of the scrotum.

Accordingly, in yet another broad form of the invention there isprovided a method of widening a penis wherein a block of fat andattached dermis (dermal fat graft) is excised from the patient, thepenis is degloved, the dermal fat graft is sutured to the exposed Bucksfascia and then reducing the penile skin.

Preferably the dermal fat grafts are harvested from either the buttocks,lower back or lower abdomen.

Preferably the dermal fat graft is sutured to the exposed Bucks fasciaprior to the tying of the sutures which maintain the lengthening of thepenis.

Accordingly, in yet another broad form of the invention there isprovided a method of enhancement phalloplasty of a human penis inpatients who are about to have or already have in place an artificialerection device; said penis having a structure including a first corpuscavernosum, a second corpus cavernosum, a corpus spongiosum, a Buck'sfascia and a dorsal neurovascular bundle; said method including thesteps of degloving the penis to expose the Buck's fascia; freeing thedorsal neurovascular bundle and separating the corpus spongiosum fromthe inferior surface of both said first and said second corpuscavernosum; dividing said first and second corpus cavernosumcircumferentially; said method further including the step of following apost-operative treatment regime.

Preferably said step of separating the corpus spongiosum from theinferior surface of both said first and said second corpus cavernosumcomprises a dissection so as to enable the first and second corpuscavernosum to be elongated without dividing the corpus spongiosum.

Preferably said artificial erection device comprises a corporal cylinderwhich is longer than the corporal cylinder presently in place, eitherwhere the patient already has an artificial erection device in place orlonger than the corporal cylinder which was measured when thecorporotomy and dilatation of the corpus was performed earlier in theprocedure.

Preferably the increase in length of the corporal cylinder is of theorder of one or more cm.

Preferably a gap formed in the first or second corpus cavernosum isfilled by suturing in place an inverted dermal graft from which theepidermis has been removed.

Preferably the dermo epidermal surface is the inner most surface appliedto the corporal cavity.

Preferably widening of the penis is also required and wherein wideningis effected by using a dermal fat graft.

Preferably the fat graft is sutured to the exposed Bucks fascia and whenthe graft reaches a defect in the Buck's fascia corresponding to thedivision of the first or second corpus cavernosum the edges of the graftare sutured to the Buck's fascia circumferentially and to a distalportion of the first or second corpus cavernosum without dividing thegraft as a separate phenomenon.

Preferably if the patient has a very thickened wall of the first orsecond corpus cavernosum, a first dermal fat graft is placed into thedefect in the Buck's fascia and then a second dermal fat graft is placedinto the defect.

Preferably if the patient has a very thickened wall of the corpuscavernosum, the gap in the wall of the corpus cavernosum is filled byusing a gortex graft, a saphenous or other vein patch, temporalis orother fascia such as the fascia lata or dexon mesh or silastic sheetingor other appropriate material and then said second dermal fat graft isapplied.

Preferably further including an additional step wherein the deglovedpenis is reduced and the proximal wounds are trimmed and closed inlayers.

Accordingly, in yet another broad form of the invention there isprovided a method of enhancement phalloplasty substantially ashereinbefore described with reference to the examples of the particularoperations given in the specification.

Preferably penile enlargement comprises one or more of lengthening orwidening.

Preferably further including the step of treatment for buried peniscondition.

Preferably said post-operative treatment regime comprises application ofa drug treatment regime.

Preferably said post-operative treatment regime comprises application ofan exercise regime.

Accordingly, in yet a further broad form of the invention there isprovided an exercise regime for application following application of theabove described method.

Accordingly, in yet a further broad form of the invention there isprovided a drug treatment regime for application following applicationof the above described method.

Accordingly, in yet a further broad form of the invention there isprovided a method of lengthening and widening a penis, the lengtheningusing the method as described above wherein a block of fat and attacheddermis (dermal fat graft) is excised from the patient, the penis isdegloved, the dermal fat graft is sutured to the exposed Bucks fasciaprior to the tying of the sutures which maintain the lengthening of thepenis.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

In order that preferred embodiments of the invention may be more readilyunderstood, I will describe certain procedures in greater detail below.

The first of these has to do with penile enlargement. This involvessuprapubic (or other type) incision and exposure of the suspensory andfundiform ligaments of the penis and their division under direct visionfrom the suprapubic area and the inferior bodies of the pubic arch (i.e.all of the antero-inferior surface of the pubic symphysis. The penis isdepressed posteriorly by approximating the medial edges of the upperends of the right and left Gracilis muscle in front of the penis. Thesuprapubic skin is rearranged (by Zplasty, excision or a combination ofboth) and sutured together and to the superior and anterior surfaces ofthe body of the pubis right and left.

To aid in the full understanding of the invention, I will more fullydescribe the procedures of preferred embodiments:

Penile Lengthening

With the patient under general aesthesia and in the supine position thelower abdomen, perineum and thighs are prepared and draped. In theclassic procedure, a transverse suprapubic incision is made measuringapproximately 3 cm in length. Various other incision can be used such asW plastys, Z plastys, vertical and peno-scrotal incisions and the like.

The incision site and the adjacent mons tissues are infiltrated withlocal anaesthetic and adrenalin. The tissues overlying the mons venerisare separated laterally and the fundiform and suspensory ligaments ofthe penis are visualized.

Dissection is carried down by a blunt technique on either side of thesuspensory ligament which is then divided under direct vision usingdiathermy. The dissection is carried out against the body of thesymphysis pubis down to the inferior pubic arch level and along theconjoined rami of ischium and pubis for a short distance. During themaneuver the assistant pulls the penis in an inferior direction placingthe ligament under tension and it can be seen under direct vision andthe neurovascular bundles can also be directly visualized and preserved.

At this point, an O Maxon (or other suture material) deep stay suture isinserted into the deep surface of the pubic symphysis and then carriedaround the right Gracilis fascia and muscle across to the left Gracilisfascia and muscle and the suture left loose. A second O Maxon (or othersuture material) is then inserted distal to the first suture so as tofurther coapt the right and left Gracilis muscles in front of the penis.Two more deep stay sutures of O Maxom (or other suture material) arethen inserted into the pubic bone inferior surface laterally and leftuntied. A fifth, sixth and seventh O Maxon (or other suture material)suture are placed into the very superior edge and anterior surface ofthe exposed symphysis pubis and left untied.

The first deep stay suture of O Maxon is then tied commencing with theone involving both Gracili which can be observed to approximate in frontof the inferiorly depressed shaft of the penis followed by tying thesecond O Maxon Gracilis suture. The tissues on each side of the monsveneris at this point are then dissected and the fundiform ligamentswhich are now clearly outlined as a result of this dissection are alsodivided under direct vision down to but not including the tissuesoverlying the spermatic cords on either side. The junction of theperineal and scrotal skin on either side is then identifiedapproximately 3 cm lateral to the midline and one each of the remainingthird and fourth O Maxon (or other suture material) sutures is/areinserted into the deep layers of the dermis of the scrotum on each sideand the sutures tied. This draws the skin of the junction side of thescrotum and perineum mediosuperiorally pushing the skin adjacent to italong the newly exposed shaft of the penis. The fifth, sixth and seventhO Maxon suture are inserted into the deep layers of the suprapubicincision in the centre and on either side and are tied so as to gentlycurve the skin of the mons veneris down over the top of the symphysispubis further aiding the movement of the abdominal skin onto the newpenile shaft.

After trimming the wound is closed in layers and dressings are applied.

Penile Widening by Dermal Fat Graft

With the patient under satisfactory general aesthesia and in the proneposition, the buttock, anal area and thighs are prepared and draped. Theareas of incision at the buttock/thigh fold on both legs, which werepreviously marked, are infiltrated with a mixture of local anaestheticand adrenalin and then the outer layers of the epidermis are dissectedoff over an area measuring of the order of 5×10 cm or more cms. Theactual size will be determined by the initial size of the penis measuredpreoperatively. Once the epidermis has been dissected free it isdiscarded. The exposed dermis, together with its layer of subtenant fatmeasuring approximately 2 cm deep is excised en bloc using a mixture ofcautery and sharp dissection.

The graft is then wrapped in a pack soaked in cold Ringer's solution andkept at room temperature (0 to 10 degrees Centigrade). The wound isclosed in layers. Dressings are applied.

The patient is then turned from the prone to the supine position whilestill anaesthetized and the lower abdomen, perineum and thighs preparedand draped.

The area of the incision is then infiltrated with a mixture of localanaesthetic and adrenalin.

If widening is done in conjunction with lengthening, the incision isusually transverse though it may be any combination of the incisionsdescribed under lengthening, above including the peno-scrotal incision.If widening is done alone then a transverse suprapubic incision isusually used although any of the above incisions may be used.

If the patient is already circumcised, infiltration of the oldcircumcision scar in its anterior half may also be carried out. If thepatient is not circumcised it is necessary to proceed to circumcisionusually, as this is a requirement for dermal fat grafting usually(though not always), then the entire circumference of the penis at theproposed circumcision site is infiltrated with local anaesthetic andadrenalin.

If the peno-scrotal approach is being used with degloving of the penis,then a completely circumferential infiltrate with local anaesthetic isused whether the patient is circumcised or not.

Once the incision, be it peno-scrotal, or more commonly transversesuprapubic, has been carried down to the deeper layers by bluntdissection, the skin and superficial fascia of the penis is separatedfrom the shaft of the underlying penis in its entire length andcircumference.

At this point, the anterior half of the old circumcision scar may bereopened (in the case of the suprapubic transverse incision) or theentire old circumcision scar or a new circumcision site is opened in thecase of the uncircumcised who require circumcision, and in the case ofthe peno-scrotal approach in the former. The penis is then degloved. Thedermal fat graft is then sutured to the exposed Bucks fascia commencingon the coronal groove distally and going as far proximally as ispossible with the wound exposure. This should be at least well down intothe infra pubic region of the symphysial or mid-portion of the penileshaft. The graft is attached all around the shaft of the penis leavingonly the corpus spongiosum exposed.

The penile skin is then reduced, the circumcision wound (if applicable)is then closed as is the peno-scrotal incision if it has been used afterthe dartos fascia has been closed.

If the suprapubic incision has been used it is closed in layers. Telfais applied to the wounds and the penis is encased in a crepe bandage asa moderately compressed dressing.

Combined Penile Lengthening and Widening

With the patient in the prone position, the dermal fat grafts areharvested as described above. The patient is then turned to the supineposition and the operation proceeds as described under penilelengthening to the point where all of the deep stay sutures are in placebut not tied. At this time, the distal circumferential incision(circumcision site incision if required) is performed, the penile skinis developed and the penis degloved. The dermal fat graft is thensutured into place as described above.

Once the penile skin has been reduced, the deep stay sutures are thentied as described above in regard to penile lengthening and attached totheir other structures. All wounds are then closed as described above.

Post-Operative Treatment Regimes

The abovementioned procedures advantageously are applied in combinationwith one or more of the following post-operative treatment regimes,namely either one or both of the stretching exercise or the drugtreatment regime.

Post-Operative Penile Scar Stretching Exercise

THE EXERCISE: The Patient stands with the right leg flexed to 90 degreesat the right (left) hip joint.

The Right (left) foot is resting on a chair or stool such that the right(left) knee is also at a right angle. The right (left) hand is passedaround the right (left) thigh from outside, under, & inside the right(left) thigh & using the index finger & thumb of the right (left) handthe Glans (head) of the Penis is grasped (only the Glans & NO part ofthe shaft skin) & pulled down & back so that the penis is pulled down &back between the Testicles & back towards the Anus. The patient pulls ashard as he can tolerate & should feel a strong pulling sensation at thebase of the penis.

TIMING: The exercise consists of ten (10) pulls (five (5) using theright hand & leg, & five (5) using the left hand & leg. Each pull is forten (10) seconds & the patient may time this using a clock or simplycount 1 &, 2 &, 3 &, 4 &, 5 &, 6 &, 7 &, 8 &, 9 &, 10 &. The patientrests for one (1) second reapplies his grip to the Glans & pulls againfor another ten (10) seconds.

This is repeated for ten (10) pulls each for ten (10) seconds. Ten (10)such pulls, each for ten (10) seconds constitute one block of exercises.The patient is required to perform three blocks per day viz. one blockon first getting out of bed in the morning, one block when he gets homefrom work, & one block just prior to going to bed at night (a total ofthirty (30) pulls per day in three blocks of ten pulls).

It is to be understood that one can use a variety of combinations oftiming and number of pulls. Each pull will always be for 10 seconds, ormultiples of 10 seconds. The number of pulls may vary and may be inexcess of 100. The preferred number of exercise blocks per day isnormally 3, but this may be varied to suit the specific situation.

Preferred ranges: 10 seconds minimum with an absolute minimum of 5seconds. Multiples of this period may run up to a maximum of 100seconds.

A possible formula to use to determine the overall regime is:pulls×seconds×repetition regime (minimum 300, maximum 1200) which can betermed the penile scar ergonomic factor.

The above regime can be used following one or more of the followingoperative procedures:

Post Operative Drug Treatment Regime

A treatment regime which can be used to advantage in respect of any ofthe above described procedures.

Initially, post-operatively a drug treatment regime can include thefollowing:

Cephalexin (Monohydrate)—500 mg orally three times a day for 14days—controls gram posotro organisms, particularly staff and the like;

Combination: Amoxycillin (Trihydrate) and Clavulamic Acid e.g. AugmentinDuoforte—one tablet twice a day orally for two weeks—deals withorganisms not commonly found at the operation site so as to lower woundinfection rate;

Al Prazolam—0.5-1 mg orally three times a day for two weeks to suppresserections;

Ketoconazole—400 mg post-operatively three times per day for twoweeks—again to suppress erections;

Mersyndol Forte—2 capsules at night for two weeks—again to suppresserection;

Prednisone—A regime of 10 mg three times a day for five days followed by10 mg twice a day for three days followed by 5 mg twice a day for twodays followed by 5 mg once a day for two days—for the purpose ofminimising the amount of local tissue swelling.

Treatment of Buried Penis

Now follows a description of the treatment of buried penis by acombination of reconstruction of the pubic area, with elevation of theparapenile and supra-penile tissues so as to reveal the buried penis inconjunction with enhancement phalloplasty as described above.

The purpose of the procedure is to enlarge the penis by recognising thatin some individuals in addition to the penis having a small length anddiameter it may also be partly buried in a proptosed supra-pubic mound.

When done in conjunction with a phalloplasty the graft donation site canbe the supra-pubic area and the size of the incision is largelydetermined by the size of the graft required to widen the penis by thetechnique of dermal fat grafting described above.

The incision (previously determined by the size of required grafts forwidening) is an elliptical incision widest in the midline and narrowestlaterally both right and left and is made in the supra-pubic area and ablock of skin and fat is removed down to the level of the externaloblique. Dermal fat grafts are harvested from this excised skin/fatblock which is divided in the midline vertically so as to produce twografts of equal size.

The grafts are harvested by making an initial incision in the skin andthen by sharp dissection removing the epidermis. The resultant dermisand fat block is then excised enmasse divided in two and used as the twografts. The infra-pubic space is then developed in the same way as forpenile lengthening.

When the deep stay sutures are in place two×0 maxon sutures are used toapproximate the gracilus in front of the displaced penis and one×1 nylondeep stay suture is placed in the front of the pubic symphysis and thiswill be used to bring the skin just proximal to the base of the penisdown onto the front of the pubic symphysis.

At this stage the penis is de-gloved and the grafts sutured in place asfor penile widening with dermal fat grafts.

After the grafts are in place and the penile skin has been reduced thenylon stay suture is inserted as described and this midline skinproximal to the penis is fixed to the front of the pubic symphysis onits infra-pubic surface. The tissues on either side are then elevatedand sutured to the external oblique upon-neurosis using 1 nyloninterrupted sutures.

Closure of the superior border of the defect created by extracting thegrafts is achieved with a combination of undercutting of the fat againstthe external oblique upon-neurosis combined with a vertical plication ofthe external oblique sufficient to allow approximation of the two edgesof skin without tension.

Deep stay suture on the front of the symphysis pubis and the attachmentof the inferior margin of the wound to the external oblique and thelongitudinal plication of the external oblique in order to bring theupper margin down so that closure is achieved without tension and thewhole effect being to raise the infra-pubic and para-penile tissues backup onto the upper surface of the pubic bone and lower abdominal wall.

Enhancement with Artificial Erection Devise:

In its broadest aspect, the invention includes a method of enhancementphalloplasty of a human penis including the steps of degloving the penisto expose Buck's fascia and dividing the corpora cavernosacircumferentially after freeing the dorsal neurovascular bundles andseparating the corpus spongiosum from the inferior surface of bothcorpora cavernosa.

The method can provide an increase in length of the penis of the orderof one centimeter and thus the corporal cylinder to be used is longer bythis amount than that presently in place or that which was measured whenthe corporotomy and dilatation of the corpus was performed earlier inthe procedure.

The particular application to which the procedure specifically relatesis to penile lengthening in patients who are about to have or alreadyhave in place an artificial erection device either of the inflatable orsolid rod type as treatment for their impotence and who requireadditional penile lengthening and/or widening.

In association with the method of the invention, I can also apply thelengthening and widening techniques described earlier in thisspecification in conjunction with the treatment regimes earlierdescribed.

The dissection involves separating the corpus spongiosum from theinferior surface of both corpora cavernosa. Additional length of 1 cm ormore in the length of the corpus cavernosum can be obtained by thistechnique and so it will be necessary to either put a 1 cm longercorporal cylinder than has already been in place or a 1 cm longercylinder than has been measured at the earlier part of the procedurewhen the corporotomy and dilatation of the corpus was performed. The gapin the corpus cavernosum is filled by suturing in place an inverteddermal graft from which the epidermis has been removed so that the dermoepidermal surface is the inner most surface applied to the corporalcavity.

Suturing is achieved using a continuous non-absorbable suture of thegortex type and suturing is performed over the deflated corporalcylinder (in the case of inflatable cylinders) or over the rigidnon-inflatable intra corporal rod if this has been used.

If widening using a dermal fat graft is also desired then the dermal fatgraft is sutured in place generally as described in my earlier patentapplication but when the graft reaches the defect in Buck's fasciacorresponding to the division of the corpus cavernosum the edges of thegraft are sutured to this circumferentially and to the distal portion ofthe corpus cavernosum without dividing the graft as a separatephenomenon. However in those patients in whom there is a very thickenedwall of the corpus cavernosum a better result can be achieved by puttinga separate dermal graft into the defect and then applying another dermalfat graft more superficially to that as described earlier in thisspecification. The same result can be achieved by filling the gap in thewall of the corpus cavernosum by using a gortex graft, a saphenous orother vein patch, temporalis or other fascia such as the fascia lata.Even substances such as dexon mesh or silastic sheeting are alsotheoretically possible.

In order that the invention may be more readily understood, I willdescribe one particular operation in which the use of the invention isdemonstrated.

This operation may be combined with penile lengthening or lengtheningand widening as described earlier in this specification or it may beperformed alone. It should also be noted that the artificial erectiondevice can be put in by the classic infrapubic or penoscrotal technique.If the latter is used it will be necessary to perform the penilelengthening by dividing the suspensory ligament having approached it bya vertical (or other) suprapubic incision.

Once the suspensory ligament of the penis and the deep stay sutures havebeen inserted as described above then the artificial erection device isinserted as per the classical description of the operation via theinfrapubic or penoscrotal route as described widely in the generalurological and surgical literature. Since additional length in thecorpora cavernosa will be achieved by the technique of corporal divisionwhich is described hereinafter, the length of the corporal cylinderchosen for the artificial erection device should be 1 cm or longer thanthat already measured for the insertion of that device. If the devicehas previously been inserted at a previous operation then it will benecessary to reopen the corporal cylinder and either attach a further 1cm rear tip extender or put in the same number of rear tip extenders asput in at the previous operation and add a 1 cm longer cylinder whichmust be new or some combination of those two possible techniques.

Once the artificial erection device is in place the penis is degloved,the artificial erection device fully inflated and the dorsalneurovascular bundle of the penis on either side of the midlinedissected free from an area approximately 2 cm proximal to the coronalgroove. This dissection is carried proximally and distally for 1 cm sothat the entire area of mobilisation is at least 2 cm long. At themidpoint of this dissection the underlying corpus cavernosum on eitherside is incised and that incision is carried around medially in themidline or laterally around to the junction with the corpus spongiosum.This latter structure is then carefully dissected away from the corpuscavernosum so that it is separated intact over an area of approximately1 cm. The division of the corpus cavernosum is then completed. Theartificial erection device is then fully inflated and maximum separationof the corpus cavernosa is achieved. At this stage a dermal graft takenfrom the original site of dermal fat graft donor area is stripped of itsfat and sutured in the circumferential manner to the free margins of thecorpus cavonosum using a continuous non-absorbable suture such as 20Gortex. When the wall of the corpus cavernosum is quite thin and whenwidening of the shaft of the penis is also being simultaneously achievedusing a dermal fat graft a separate dermal graft to fill this defect isnot necessary and the deep layers of the dermal fat graft can be suturedto the free edges of the corpus cavonosum instead. During the suturingprocess it is both important more convenient for the artificial erectiondevice to be deflated thereby minimising the risk of perforation of thatdevice with the needle during the suturing process.

At this stage the degloved penis is then reduced, the distal penile skinincision is closed with a running absorbable suture, the deep staysutures in the infrapubic region are tied, the proximal wounds aretrimmed and closed in layers and dressings are applied.

If the artificial erection device has been in place for some time it isthen inflated and left inflated for 24 hours. Dressings are thenapplied. If the artificial erection device has been put in at the timeof surgery as a new device then it is left deflated and a tightcircumferential penile dressing applied.

Fenestration Technique

In a variation of the above described technique for enhancement in thecontext of the existence of an artificial erection device the penis canbe dismembered utilising the following alternative technique tocircumferential division and graft in one place:

The fenestration technique comprises separation of the three corporaalong the entire length of the penile shaft external to the perineum.

The corpora cavernoso are then incised from 12 o'clock to 6 o'clock onthe right hand side of each corpus; a distance of approximately 1 cm (ormore or less) between each incision.

Then the left hand side of each corpus is incised from 12 o'clock to 6o'clock midway between two adjacent right hand incisions and this seriesof alternate incisions is carried the entire length of the penile shaft.

Whilst I have described herein specific embodiments of the concepts ofthe present invention it is to be understood that variations can be madein this within the ambit of the invention.

For example a modification on the above fenestration technique cancomprise lateral fenestration only of the corpora cavernosa with orwithout separation of the three corpora.

1. A method of widening a penis wherein a dermal fat graft comprising ablock of fat and attached dermis is excised from the patient, the penisis degloved, the dermal fat graft is sutured to the exposed Bucks fasciaand then reducing the penile skin; said method further including thestep of following a post-operative treatment regime.
 2. The method asclaimed in claim 1 wherein the dermal fat grafts are harvested fromeither the buttocks, lower back or lower abdomen.
 3. A method ofwidening a penis wherein a block of fat and attached dermis (dermal fatgraft) is excised from the patient, the penis is degloved, the dermalfat graft is sutured to the exposed Bucks fascia and then reducing thepenile skin.
 4. A method as claimed in claim 3 wherein the dermal fatgrafts are harvested from either the buttocks, lower back or lowerabdomen.
 5. A method of lengthening and widening a penis, thelengthening includes the steps of placing the suspensory ligament undertension in the inferior direction; dividing the suspensory ligamentagainst the body of the symphysis pubis down to the inferior pubic archand along the inferior surface of both the right and left conjoinedinferior pubic rami; effecting suturing to retain the penis releasedfrom the suspensory ligament in an inferior position by coapting theproximal medial attachments of the right and left gracilus muscletogether ventral the released penis, dividing the fundiform ligaments,drawing the skin of the junction site of the scrotum and the perineummediosuperiorally so as to attach it to the symphysis pubis therebypushing the skin adjacent thereto along the newly exposed shaft of thepenis and suturing this to retain this position; said method furtherincluding the step of following a post operative treatment regime andthe widening using a method wherein a dermal fat graft comprising ablock of fat and attached dermis is excised from the patient, the penisis degloved, the dermal fat graft is sutured to the exposed Bucks fasciaand then reducing the penile skin; said method further including thestep of following a post-operative treatment regime wherein the dermalfat graft is sutured to the exposed Bucks fascia prior to the tying ofthe sutures which maintain the lengthening of the penis.
 6. A method ofenhancement phalloplasty of a human penis in patients who are about tohave or already have in place an artificial erection device; said penishaving a structure including a first corpus cavernosum, a second corpuscavernosum, a corpus spongiosum, a Buck's fascia and a dorsalneurovascular bundle; said method including the steps of degloving thepenis to expose the Buck's fascia; freeing the dorsal neurovascularbundle and separating the corpus spongiosum from the inferior surface ofboth said first and said second corpus cavernosum; dividing said firstand second corpus cavernosum circumferentially; said method furtherincluding the step of following a post-operative treatment regime. 7.The method as claimed in claim 6 wherein said step of separating thecorpus spongiosum from the inferior surface of both said first and saidsecond corpus cavernosum comprises a dissection so as to enable thefirst and second corpus cavernosum to be elongated without dividing thecorpus spongiosum.
 8. The method as claimed in claim 6 wherein saidartificial erection device comprises a corporal cylinder which is longerthan the corporal cylinder presently in place, either where the patientalready has an artificial erection device in place or longer than thecorporal cylinder which was measured when the corporotomy and dilatationof the corpus was performed earlier in the procedure.
 9. A method asclaimed in claim 7 wherein the increase in length of the corporalcylinder is of the order of one or more cm.
 10. A method as claimed inclaim 6 wherein a gap formed in the first or second corpus cavernosum isfilled by suturing in place an inverted dermal graft from which theepidermis has been removed.
 11. A method as claimed in claim 10 whereinthe dermo epidermal surface is the inner most surface applied to thecorporal cavity.
 12. A method of enhancement phalloplasty as claimed inclaim 6 wherein widening of the penis is also required and whereinwidening is effected by using a dermal fat graft.
 13. The method ofclaim 12 wherein the fat graft is sutured to the exposed Bucks fasciaand when the graft reaches a defect in the Buck's fascia correspondingto the division of the first or second corpus cavernosum the edges ofthe graft are sutured to the Buck's fascia circumferentially and to adistal portion of the first or second corpus cavernosum without dividingthe graft as a separate phenomenon.
 14. A method of enhancementphalloplasty as claimed in claim 13 wherein if the patient has a verythickened wall of the first or second corpus cavernosum, a first dermalfat graft is placed into the defect in the Buck's fascia and then asecond dermal fat graft is placed into the defect.
 15. A method ofenhancement phalloplasty as claimed in claim 14 wherein if the patienthas a very thickened wall of the corpus cavernosum, the gap in the wallof the corpus cavernosum is filled by using a gortex graft, a saphenousor other vein patch, temporalis or other fascia such as the fascia lataor dexon mesh or silastic sheeting or other appropriate material andthen said second dermal fat graft is applied.
 16. A method as claimed inclaim 6 further including an additional step wherein the degloved penisis reduced and the proximal wounds are trimmed and closed in layers.